Nurse Manager - Utilization Review

Huron helps its clients drive growth, enhance performance and sustain leadership in the markets they serve. We help healthcare organizations build innovation capabilities and accelerate key growth initiatives, enabling organizations to own the future, instead of being disrupted by it. Together, we empower clients to create sustainable growth, optimize internal processes and deliver better consumer outcomes.

Health systems, hospitals and medical clinics are under immense pressure to improve clinical outcomes and reduce the cost of providing patient care. Investing in new partnerships, clinical services and technology is not enough to create meaningful and substantive change. To succeed long-term, healthcare organizations must empower leaders, clinicians, employees, affiliates and communities to build cultures that foster innovation to achieve the best outcomes for patients.

Joining the Huron team means you’ll help our clients evolve and adapt to the rapidly changing healthcare environment and optimize existing business operations, improve clinical outcomes, create a more consumer-centric healthcare experience, and drive physician, patient and employee engagement across the enterprise.

Join our team as the expert you are now and create your future.

The Manager of Utilization Management is responsible for planning, organizing, developing, and directing implementation of the Utilization Review Plan and the overall operation of the Utilization Management Department in accordance with federal, state and local guidelines, regulatory agencies, and hospital contractual payor agreements. This position reports to the Director of Utilization Management and works with hospital leadership to coordinate and integrate utilization management activities, using continuous quality improvement initiatives to promote positive patient outcomes. Coordinates data collection and reporting to verify outcomes, effectiveness of utilization management activities and appropriate use of resources, to achieve appropriate length of stay and level of care, while promoting cost-effective and quality patient care.

*** Position is located in Annapolis, MD ***

• Staff Acquisition and Support: Leads and manages the utilization review staff and function for the system, reporting to the Director of Utilization Management within Revenue Cycle. Assists with leading recruiting, orienting, and assigning staff for caseload responsibilities. Provides guidance for staff performance, including evaluation, orientation, and maintaining competency requirements, offering feedback, and implementing disciplinary measures as needed.
• Team Guidance and Leadership: Determines policies and procedures that incorporate best practices and ensure effective utilization review. Organizes and leads team meetings, providing education on access management, observation, medical necessity, and CMS guidelines. Regularly offers performance feedback and strategic outcome measures to leadership. Leads team in prioritization of workload to ensure work is covered and goals are met.
• Performance Tracking and Improvement: Provides analysis and reports of utilization, denials, and appeals KPIs, trends, patterns, and impacts to resources. Tracks, analyzes, and implements strategies to improve team performance based on utilization trends and identifies performance indicators, initiates monitoring process improvements. Accountable to PI performance.
• Compliance and Regulatory Oversight: Demonstrates knowledge of regulatory and accreditation requirements, ensuring compliance with Maryland state law, Medicare, Medicaid, and third-party payer standards. Oversees completion of utilization reviews in accordance with relevant policies.
• Interdisciplinary Collaboration: Consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Ensures collaboration among health system team members regarding capacity and resource decisions, frequently collaborating as a resource for physicians, nurses, and other healthcare professionals.
• Professional Judgement in Utilization Review: Employs sound professional judgment to evaluate severity of illness and intensity of services, escalating cases as necessary to payers, physician advisors, leadership, or the medical team.
• Physician Advisor Relationship: Works closely with employed physician advisors to support decision-making and adherence to care standards.
• On-site Review Preparation: Assists in preparation for on-site reviews by outside review organizations and ensures readiness for external evaluations.
• Standards of Care Compliance Monitoring: Monitors compliance with standards of care through observation and documentation, communicating results and implementing corrective actions to address deficiencies.
• Contract and Resource Management: Understands contract language requirements, providing guidance to teams, and ensures appropriate management of resource use within established guidelines.
• Revenue Cycle Collaboration: Conduct outreach to other functional leaders across Revenue Cycle to ensure alignment and support for denial prevention and performance improvement initiatives that Utilization Review impacts. Attend and participate in Revenue Cycle department meetings and governance to ensure strong Utilization Review team contributions to health system performance and goals.

Requirements

• BSN is required. Master’s Degree in nursing or related field preferred.
• 5 years recent Utilization Management experience required; Maryland experience desired.
• 2+ years of UM/CM managerial experience strongly preferred.
• Expert knowledge of InterQual Level of Care Criteria and Milliman Care Guidelines (MCG) preferred.
• Current RN license from Maryland Board of Nursing.
• CCM or ACM certification preferred
• Epic experience preferred
• Onsite/in-office work in Annapolis, Maryland required

The estimated salary range for this job is $90,000 - $125,000.  The range represents a good faith estimate of the range that Huron reasonably expects to pay for this job at the time of the job posting. The actual salary paid to an individual will vary based on multiple factors, including but not limited to specific skills or certifications, years of experience, market changes and required travel.  This job is also eligible to participate in Huron’s annual incentive compensation program, which reflects Huron’s pay for performance philosophy and Huron’s benefit plans which include medical, dental and vision coverage and other wellness programs. The salary range information provided is in accordance with applicable state and local laws regarding salary transparency that are currently in effect and may be implemented in the future.

Position Level

Manager

Country

United States of America